Role of Antipsychotic Agents in Dementia-Associated Neuropsychiatric Symptoms: Efficacy, Safety, and Deprescribing Strategies

Abstract

Background. Dementia syndromes involve cognitive and functional decline and frequent neuropsychiatric symptoms, including agitation, aggression, and hallucinations. These symptoms increase caregiver burden, institutionalization, and loss of quality of life. Antipsychotics remain relevant but controversial because benefits are modest and risks substantial.

Aim. This review summarizes evidence and guideline recommendations on the role, indications, monitoring and deprescribing of antipsychotics in dementia-related neuropsychiatric symptoms.

Material and methods. This narrative review was based on selected guidelines, systematic reviews, network meta-analyses, randomized trials and observational studies on antipsychotic use in dementia-related neuropsychiatric symptoms

Results. Antipsychotics should not be routine first-line treatment. Before pharmacotherapy, reversible causes such as pain, delirium, infection, dehydration, drug effects and environmental triggers should be assessed. Psychosocial and environmental interventions remain fundamental. Antipsychotics may be considered only in selected patients with severe agitation, aggression or psychosis causing distress or risk of harm. Evidence supports modest efficacy mainly for agitation and aggression, whereas effects on psychosis are less consistent. Risperidone is a well-established option for severe aggression and agitation in Alzheimer’s disease, while brexpiprazole has emerged as an option for agitation in Alzheimer’s dementia. Treatment requires individualized risk-benefit assessment because of sedation, extrapyramidal symptoms, falls, cerebrovascular events, pneumonia, acute kidney injury, thromboembolism and mortality.

Conclusions. Antipsychotics have a restricted but important role in dementia care. Their use should be symptom-targeted, time-limited, monitored and linked to deprescribing.